2015 Army Health of the Force report

Create a healthier force for tomorrow.
HEALTH
FORCE
OF THE
NOVEMBER 2015

Introduction
Performance Triad
Sleep
Activity
Nutrition
Installation Health Index
Medical Readiness
Health Outcomes
Health Factors
Healthcare Delivery
Installation Profile Summaries
Appendices
1
3
9
13
17
21
31
35
49
69
72
102

WE CAN STRENGTHEN THE
HEALTH OF OUR NATION
by improving the health of our
Army. The Army is enhancing
health readiness by ensuring
the Total Force has the required
physical, emotional, and cog-
nitive health and fitness to win
in environments that are com-
plex, unknown, and constantly
changing. As leaders, we must have the knowledge and
resources to influence cultural change that best facilitates
personal health readiness and creates environments
where the healthy choice is the easy choice.
The “Health of the Force Report” is the Army’s first
attempt to review, prioritize, and share best health
practices at the installation level. Senior Army Leaders
now have the “Health of the Force” to track the health
of the Army, installation by installation, and to share
lessons learned for those installations on different ends
of the health spectrum. This effort is in direct concert
with the U.S. Surgeon General’s recent plan to establish
national goals and objectives for improving the health
of all Americans through leading health Indicators in
an attempt to facilitate sharing of best health practices.
Ultimately we want to improve the health readiness of
the Total Force with the intention to compel leaders to
improve the environment, infrastructure, and nutrition
offerings on our installations. By exploring and illumi-
nating emerging and best practices, we are aggressively
responding to a national call-to-action regarding health.
The inaugural “Health of the Force Report” ushers in an
era of reporting that promotes health and prevention
rather than just the treatment of chronic illness, injury
and disease. For the Army community to achieve mean-
ingful change in health readiness, it must first under-
stand related objective data. As an initial foray into such
understanding, I hope this product highlights the Army’s
current successes and serves as motivation to achieve
great personal health readiness at the individual, unit,
and community levels. Our Soldiers, Civilians, and Fami-
lies deserve nothing less.
Serving to Heal…Honored to Serve!
THE 2015 “HEALTH OF THE FORCE REPORT”
provides a snapshot of the health of active component
Soldiers on U.S.-based installations during 2014. It was
influenced by the Army Unit Status Report and the U.S.
Department of Health and Human Services (HHS) peri-
odic report that tracks Leading Health Indicators (LHI)
across the United States.1
The report aligns with the
Army’s Ready and Resilient mission and other programs
such as Army’s Human Dimension, DoD’s Operation Live
Well, the Military Health System’s Quadruple Aim, the
Veterans Administration’s Whole Health Initiative, and
HHS’s National Prevention Strategy.
The “Health of the Force Report” presents summaries
of key Performance Triad (P3) measures and creates an
overall Installation Health Index (IHI). This first effort,
still in its infancy, is part of the Army’s movement toward
creating improved transparency regarding popula-
tion-level information on health, wellness, and the built
environment. The intention is for the Army to use to the
information to better understand variation among the
installations as they relate to the presence or absence
of health outcomes, or unhealthy behaviors, based on
LHIs. It is also a means to improve key P3 measures
(sleep, activity, and nutrition). Future versions will not
only refine existing measures and indices, but will also
incorporate additional installations and new data as
they become available.
We will continue the pursuit of innovative solutions
through rigorous analyses, and by leveraging growing
partnerships in a spirit that ensures the healthy choice is
the easy choice where Soldiers, Civilians, and Families
live, work, and play.
1 HEALTH OF THE FORCE INTRODUCTION 2
PERFORMANCE TRIAD
In 2014, Global Assessment Tool (GAT) data suggest
that Soldiers could improve their personal health
readiness through changes in their sleep, activity, and
nutritional habits. No installations reached the current
targeted score of 85 or above out of 100 possible
points on sleep, activity, or nutrition.
Additionally, a cross-section of 2014 GAT data revealed
that only 15%, 38%, and 13% of Soldiers met all of the
recommended P3 targets for sleep, activity, and nutri-
tion, respectively.
SLEEP
The overall installation score for optimal sleep
levels (e.g., sleep duration, satisfaction, and
being bothered by poor sleep) among Active
Duty Soldiers was 67 out of 100. Scores ranged
from 64 to 74 across installations.
ACTIVITY
The overall installation score for optimal physical
activity as assessed by Body Mass Index (BMI),
moderate or vigorous activity levels, resistance
training and low intensity activity was 81 out of 100.
Scores ranged from 79 to 85 across installations.
NUTRITION
The overall installation score for optimal nutrition-
al intake (e.g., healthy eating, breakfast, recovery
snacks, water consumption) among Active Duty
Soldiers was 69 out of 100. Scores ranged from
67 to 75 across installations.
MEDICAL READINESS
Medical readiness within 72 hours was not achieved by
17% of AD Soldiers. One-third of those not medically
ready were Soldiers with overdue dental or medical
exams.
INJURIES
Injuries affect nearly 300,000 Soldiers annually; some
individuals experience multiple injuries in a single
year, impacting personal readiness and increasing the
burden on medical systems. Approximately 1,295 new
injuries per 1,000 AD Soldiers were diagnosed in 2014.
BEHAVIORAL HEALTH
Roughly 15% of AD Soldiers had a diagnosed behav-
ioral health disorder (range: 9 to 20% across installa-
tions). Among behavioral health diagnoses, adjustment
disorder, mood disorders and anxiety disorders were
more common.
CHRONIC DISEASE
Among the AD Soldiers evaluated, approximately
14% had one or more diagnosed chronic conditions
(range: 12 to 21% across installations). Cardiovascular
conditions were the most common condition assessed,
followed by arthritis, asthma and COPD.
OBESITY
Obesity remains a concern for military readiness as 13%
of Soldiers were classified as obese during Army Phys-
ical Fitness Tests (APFTs). Prevalence ranged from 9 to
18% across installations.
TOBACCO
Approximately 32% of AD Soldiers reported tobacco
use (smoke or smokeless), with use ranging from 13 to
SLEEP DISORDERS
Approximately 10% of AD Soldiers had a diagnosed
sleep disorder (range across installations: 5 to 14%).
SUBSTANCE ABUSE
Approximately 2% of AD Soldiers had a diagnosed
substance abuse disorder (range across installations:
1 to 3%).
CHLAMYDIA
Approximately 16.7 chlamydia infections were reported
per 1,000 AD Soldiers.
HOSPITAL ADMISSIONS
Preventable hospital admissions were low (2%) among
AD personnel.
INSTALLATION HEALTH INDEX
Installation scores were not significantly different from
the Army average, indicating that installations were
similar to each other across evaluated health measures.
Strengthen the Health of Our Nation
Why Measure Health of the Force?
Lt. Gen. Patricia D. Horoho
43rd U.S. Army Surgeon General
and Commander, U.S. Army Medical Command
Mr. John J. Resta
Deputy Chief of Staff-Public Health (Acting)
REPORT HIGHLIGHTS
1 https://www.healthypeople.gov/

3 HEALTH OF THE FORCE PERFORMANCE TRIAD 4
l Overview
l Sleep
l Activity
l Nutrition

S
leep, activity and nutrition (SAN) are critical for
achieving optimal physical, mental, and emotion-
al health and wellbeing. They are integral to max-
imizing Soldier performance and are the cornerstones
of the Performance Triad (P3). P3, which is rooted in the
Army’s adaptation of the McKinsey Global Institute’s
model (see Appendix I), integrates the best available
SAN sports science to improve squad overmatch
and Soldier performance in tactical environments. It
includes messaging, curriculum and training, policy
development, technology, leader development, and
changes within the built installation environment to
make the healthy choice the easy choice. P3 strives to
improve and sustain healthy SAN knowledge, attitudes,
behaviors, and associated outcomes among Soldiers
and Army beneficiaries.
The Global Assessment Tool (GAT) is a survey tool
designed to assess an individual’s behaviors with regard
to these triad components and other key elements
which can impact wellbeing. In 2014, approximately
85,000 Active Duty Soldiers completed the survey each
quarter, on average; this amounts to roughly 340,000
Soldiers or two thirds of the Active Duty Soldier popula-
tion completing the GAT over the course of the year.
GAT-derived SAN summary scores available in the
Strategic Management System (SMS) were used for this
review; the maximum possible score for each metric
was 100. Quarterly installation scores were averaged
to generate 2014 estimates. These estimates were
then collated to generate an installation P3 index (IPI),
reflecting overall deviations from the Army average. The
IPI assessment revealed that only 1 installation had a
statistically significant deviation, and that deviation was
indicative of positive P3 health behaviors.
5 HEALTH OF THE FORCE
Performance Triad
See Installation Profile Summary Pages for installation P3 scores and Appendix II for additional details regarding methodology.
OVERVIEW
1) medically non-deployable status
2) first term attrition
3) obesity and nutrition
4) musculoskeletal injury (MSKI)
5) fatigue
20,000 (36%) of newly accessioned Soldiers
do not complete their first term of enlistment.*
78,000 Active Duty Soldiers are considered
clinically obese (Body Mass Index > 30) and are
less likely to be medically ready to deploy.*
=1,000 Soldiers
Performance Triad Return on Readiness
Performance Triad: Optimizing Human Performance & Unit Readiness
Just one sleepless
night (<4 hours) can
impair performance
as much as 0.10%
blood-alcohol level
43K active duty (~12
BCTs) are non-deploy-
able due to medical
profiles
10% decrease in over-
weight Soldiers
enables FORSCOM
90% deployable goal
$137M annually to
replace Soldiers
discharged due to
weight control ($75.9K
per new recruit)
Under 7 hours sleep for
3+ days correlates to a
20% decrease in cogni-
tive ability (memory &
decision-making)
$4.2B to train and
replace all Soldiers BMI
>30* (currently 78,734
active duty Soldiers)
who are 36% less likely
to deploy
5+ fruit & vegetables is
associated with a 5-fold
increase in mental
well-being compared to
1 portion
Programs to improve
health can result in
a $3.27 return on
investment for every
prevention
Fatigue was a con-
tributing factor in 628
Army accidents and
32 Soldier deaths
(FY11–14)
10 million limited days
of duty of COMPO 1
Soldiers on duty limited
profiles
Overweight recruits
are 47% more likely to
become injured and
use 49% more health-
care resources in first
90 days
Performances Triad
Pilot study baseline
reports 99.6% of
Soldiers do not meet
all target behaviors
“All three elements of the PerformanceTriad are equal in
importance.The command emphasis on nutrition and sleep must
match the emphasis on physical training.”
— FORSCOM CommandTraining Guidance ,19 October 2015,
General Robert B.Abrams,Commander,U.S.Forces Command,United StatesArmy
180,000Active Duty Soldiers have at least
one musculoskeletal injury (MSKI) per year, re-
sulting in over 10 million limited duty days. MSKI
accounts for 76% of the medically non-deploy-
able population.*
*Adapted from System for Health Playbook, OTSG July 2015
PERFORMANCE TRIAD 6
Poor sleep, activity and nutrition have been associated with the top 5 challenges to
personal readiness:*

2
1
IPI 0
3
-3
Army Average
-1
-2
“WE MUSTALSO BEGINTOVIEW HEALTHAS MORETHAN
SIMPLY HEALTHCARE,ANDTRANSITIONTHEARMYTOAN
ENTIRE SYSTEM FOR HEALTHTHAT EMPHASIZESTHE
PERFORMANCETRIAD—SLEEP,ACTIVITYAND NUTRITION—
ASTHE FOUNDATION OFA READYAND RESILIENT FORCE.
Performance Triad Target Card
—The Army Posture Statement, 25 March 2014
Honorable John M.McHugh,Secretary of theArmy
& General RaymondT.Odierno,Chief of Staff United StatesArmy
”
Performance Triad OVERVIEW
For this review, each of the P3 behaviors were assessed individually, after which an overall
installation P3 index (IPI) which collated the measures was computed. Each installation was
assessed against the average for the installations evaluated to determine potentially signif-
icant standard deviations. Overall, the installations were relatively comparable, with only 1
installation reporting statistically significant positive P3 behaviors.
* Positive IPI scores indicate higher collective sleep, activity, and nutrition scores; Scores ≤ -2 or ≥ 2 represent statistically
significant differences from the Army average (0)
Variation by Installation
IPI Scores*

Performance Triad
Sleep
Optimal sleep is critical to mission success. In
training and on the battlefield, inadequate sleep
impairs essential abilities such as reaction times,
the ability to detect and engage the enemy, and
squad tactic coordination. When interviewed about
the connections between sleep and mission read-
iness, Soldiers and military leaders consistently
associate lack of sleep with accidents, poor morale,
and impaired judgment. However, despite mission
degradation resulting from sleepiness, a culture
of suboptimal sleep and a perception that lack of
sleep is “the Army way” prevails in the force.
The P3 curriculum and its targets focus on improv-
ing performance while addressing root causes of
poor sleep and fatigue. The P3 curriculum incorpo-
rates goals from the clinical practice guidelines for
insomnia established by the American Academy
of Sleep Medicine and leverages technology to
allow Soldiers and leaders to effectively monitor
and improve sleep. P3 provides tactical sleep
techniques and specific information on how to use
caffeine/energy drinks to improve performance
while minimizing their impact on sleep. In conjunc-
tion with these strategies, the P3 team is striving
to empower leaders to make policy and environ-
mental changes to enable their Soldiers to obtain
adequate sleep each night in garrison and plan for
sleep while on field missions.
SLEEP
PERFORMANCE TRIAD 10
THESE SOLDIERS ARE LESS LIKELY TO BE MEDICALLY READY TO DEPLOY**
1 in 20ACTIVE DUTY SOLDIERS
ARE PRESCRIBED SLEEP MEDICATIONS
Overall, installations had an average sleep
score of 67 out of 100 based on Soldier
responses to GAT questions assessing sleep
duration, sleep satisfaction, and being both-
ered by poor sleep.
67
**Adapted from System for Health Playbook, OTSG July 2015
Ŧ Based on a cross-section of GAT surveys completed by AD Soldiers in 2014 (n=175,612)
Percent of AD Soldiers Meeting National Goals and Standards for SleepŦ
55%did not meet
targets
30%met some
targets
15%met all
targets

Performance Triad SLEEP
A sleep-deprived individual is not aware of his/her own
impairments and is more at risk to develop symptoms of
depression, anxiety, and PTSD.*
Individuals who routinely get 5–6 hours of sleep perform
much like a person with a blood alcohol content of 0.08.*
Sleep is likely to be limited in continuous operations,
depending on operational tempo and mission demands.
Leaders are responsible for implementing deliberate
sleep management strategies and must ensure these are
included in mission planning.*
Nearly 1/3 of Soldiers get 5 hours of sleep or less per
night, an amount linked to increased risk of behavior
health disorders, illness, and musculoskeletal injuries.Ŧ
Almost 62% of Soldiers get less than 7 hours of sleep
per night.Ŧ
Almost half of service members have a clinically significant
sleep problem that results in 33% of service members
reporting fatigue 3–4 days/week with 16.9% reporting
sleep problems that impair their daytime military functions.Ŧ
* Performance Triad Challenge Guide, 2015
Ŧ System for Health Playbook, OTSG July 2015
“SLEEP IS IMPORTANT
TO PUBLIC HEALTH,
WITH SLEEP INSUFFICIENCY
LINKEDTO MOTOR
VEHICLE CRASHES,
INDUSTRIAL DISASTERS,
MEDICALAND OTHER
OCCUPATIONAL ERRORS.
— CENTERS FOR DISEASE CONTROLAND PREVENTION
”

ACTIVITY
Activity
Performance Triad
Physical fitness and activity are crucial to ensur-
ing Soldiers are able to perform the duties and
responsibilities of their jobs. Practicing principles
of safe and effective training enables Soldiers to
maintain physical readiness and health. Soldiers
and leaders across the Army agree that activity and
fitness are essential to being a strong warfighter.
Although Soldiers are generally more physically
active than civilians, they are frequently at risk for
overtraining and resulting injuries. Profiles and
Army Physical Fitness Test failures are both associ-
ated with medical non-deployability. And, despite
obtaining some activity through structured unit
physical readiness training, many Soldiers are then
sedentary over the course of the day, which can
lead to adverse health outcomes over time.
Based on the unique physical requirements and
demands of today’s Soldier athletes, P3 provides
information and strategies to ensure our force
obtains optimal, balanced activity. The curriculum
and targets inform Soldiers and leaders on how to
practice safe running, use proper resistance train-
ing techniques, prevent overtraining, and increase
daily physical activity. By leveraging principles of
functional fitness, balanced training approaches,
targeted athletic development, and movement
throughout the day, P3 promotes the best avail-
able evidence to support Soldiers in meeting the
physical and mental demands of their missions.
THESE SOLDIERS ARE ALMOST 3 TIMES LESS LIKELY
TO BE MEDICALLY READY TO DEPLOY**
1 in 20ACTIVE DUTY SOLDIERS
FAIL THE APFT ANNUALLY
Percent of AD Soldiers Meeting National Goals and Standards for ActivityŦ
34%did not meet
targets 28%met some
targets
38%met all
targets
Overall, installations had an average activ-
ity score of 81 out of 100 based on Soldier
responses to GAT questions assessing exercise
frequency, exercise intensity, resistance train-
ing, and BMI.
81

ACTIVITYPerformance Triad
Exercise and movement help build key mental abilities—
memory, reaction time, attention span, and learning. These
are essential for Soldiers to perform their best and to
accomplish any mission.*
Being a Soldier can be a stressful job. Exercise and activity
help you manage stress, perform at your best, and stay in
the fight. Exercise helps you keep your mental edge!*
Soldiers using strength and cross-training have up to 50%
fewer injuries and do better on functional testing.*
Only 68.8% of Soldiers get at least 150+ minutes of
moderate aerobic endurance training/week and 57%
get at least 75 minutes of vigorous aerobic endurance
training/week.Ŧ
Only 47% of Soldiers get 3 or more days of strength
training/week.Ŧ
“NOTHING IS MORE CONDUCIVE
TO KEEPINGANARMY IN GOOD
HEALTHAND SPIRITSTHAN
EXERCISE;THEANCIENTS USEDTO
EXERCISETHEIRTROOPS EVERY
DAY.PROPER EXERCISE,THEN,IS
SURELY OF GREAT IMPORTANCE
FOR IT PRESERVESYOUR HEALTH
IN CAMPAND SECURESYOUR
VICTORY INTHE FIELD.
— NICCOLO MACHIAVELLI
THEART OFWAR,1521
”

NUTRITION
Nutrition
Performance Triad
Eating or fueling for performance enables Soldier
training, increases energy and endurance, short-
ens recovery time between activities, improves
focus and concentration, and helps leaders and
Soldiers look and feel better. Although Soldiers
and leaders frequently understand the connec-
tions between nutrition and mission readiness,
they also cite numerous barriers to obtaining
optimal nutrition. These barriers include lack of
access to healthy foods, time constraints aris-
ing from working through meals or working late,
monetary constraints, and low motivation to make
healthy choices. Specifically, when interviewed on
what affects their nutrition, many Soldiers cited
military dining facility hours, cost, location, and
limited healthy options as barriers to making the
healthy choice. Others indicated the prevalence
of unhealthy on-base fast food options detracted
from their ability and motivation to make optimal
food selections.
As part of the institutional agility elements of the
Army adaptation to the McKinsey model (Appen-
dix I), P3 is working hard to facilitate changes within
the nutrition environment on Army installations
via policy changes and facility improvements. The
intent of making the healthy, performance-oriented
choice the easy choice is to reduce identified barri-
ers to optimal nutrition. In conjunction with modi-
fying the Army nutrition environment, P3 nutrition
curriculum teaches Soldiers about nutrients need-
ed to complete mission tasks, describes refueling
techniques, and details strategies for creating
a nutrition plan. Specific areas of focus include
hydration, nutrient timing, dietary supplements,
field nutrition, and healthy weight maintenance.
Percent of AD Soldiers Meeting National Goals and Standards for NutritionŦ
ONE-THIRD OF
SOLDIERS REPORT
THAT HEALTHY
FOODS ARE TOO
EXPENSIVE.
33% 30% OF SOLDIERS
REPORT NOT HAVING
ENOUGH TIME TO
PREPARE HEALTHY
FOODS.
Overall, installations had an average nutri-
tion score of 69 out of 100 based on Soldier
responses to GAT questions assessing healthy
eating, breakfast, recovery snacks and water
consumption.
69
34%did not meet
targets
13%met all
targets
29%met some
targets

NUTRITIONPerformance Triad
Poor sleep and activity decrease brain function related
to making good decisions. Studies show that this reduced
function increases cravings and intake of high-calorie
junk foods.*
Making poor nutrition choices and not fueling regularly
throughout the day can decrease alertness and your ability
to think clearly and concentrate.*
Deployments and field operations demand a properly
fueled body. Proper fueling can mean the difference
between top performance and mission failure.*
Only 10.8% if Soldiers eat 3 or more servings of fruits
per day.Ŧ
Only 12.9% of Soldiers eat 3 or more servings of
vegetables per day.Ŧ
“THE PRESERVATION OFA
SOLDIER’S HEALTH SHOULD
BETHE COMMANDER’S
FIRSTAND GREATEST CARE.
— Regulation for Order and Discipline of theTroops,1779
”

l Overview
l Medical Readiness
l Health Outcomes
l Health Factors
l Healthcare Delivery
INSTALLATION HEALTH INDEX 22

Installation Health Index OVERVIEW
23 HEALTH OF THE FORCE INSTALLATION HEALTH INDEX 24
The assessment revealed a rather homogeneous Active Duty force in terms of health, with
the majority of installations categorized as relatively healthy when compared to other installa-
tions. None of the installations evaluated had statistically significant deviations from the Army
average as determined by the IHI.
Healthiest and Least Healthy Counties within each State, County Health Ranking 2014
Installation Health Index (IHI)
Health indices are widely used in civilian settings to
gauge the health of populations. They offer an evi-
dence-based tool for making valid comparisons of
leading health indicators (LHIs) across communities
and inform community health needs assessments.
Health indices have been examined at the state
level by the United Health Foundation for 25 years
and more recently by the Robert Wood Johnson
Foundation (RWJF) at the county level. A shared
objective between these organizations is the gen-
eration of health rankings for the communities
evaluated. The ultimate goal of using rankings is
to create positive change in health. Rankings drive
health improvements in a community by stimulating
interest across groups, including social media and
decision makers. By providing an effective and intui-
tive means of summarizing complex information,
rankings can also support funding and resources to
support health needs and motivate communities to
take actions to improve their health.
The Installation Health Index (IHI) follows in the
footsteps of these successful initiatives. The LHIs
selected were prioritized based on a review of
measures recommended by the United Health
Foundation, RWJF and other nationally recognized
public health authorities. Indexing techniques were
likewise modelled after established practices, and
selected measures were adapted as needed for
relevancy to the Soldier population.
The 10 core measures included in this report were
prioritized as LHIs for the Active Duty Soldier pop-
ulation based on the prevalence of the condition
or factor, the potential health or readiness impact,
the validity of the data, supporting evidence, and
the importance to Army leadership. Data avail-
ability ultimately limited which measures could be
included in this initial assessment and which instal-
lations could be evaluated.
Each measure was individually assessed by instal-
lation against the Army average for the U.S.-based
installations evaluated and collated into the IHI.
Negative differences from the Army reference
values indicated lower levels of adverse health and
readiness outcomes and behaviors, while positive
deviations indicated higher levels; therefore, lower
index scores reflect better overall health.
While health indices provide a comprehensive
measure of health that may help identify popula-
tions that could potentially benefit from enhanced
prevention measures, they may hide some of the
driving factors. A review of the individual mea-
sures from which the index is derived is necessary
to identify and effectively target key outcomes or
behaviors that are the most significant health and
readiness detractors for each installation.
See Installation Profile Summary Pages for IHI
scores and Appendix II for additional details
regarding methodology.
Medical Readiness
Medically Non-ready
Healthcare Delivery
Preventable
Admissions
Health Factors
Obesity
Tobacco
Sleep Disorders
Substance Abuse
Chlamydia
Health Outcomes
Injury
Behavioral Health Disorders
Chronic Disease
REFERENCE: Remington PL, Catlin BB, Gennuso KP. The County Health Rankings: rationale and methods. Population Health
Metrics (2015) 13:11, published online: 17 April 2015
Least Healthy Most Healthy Unranked County
* Negative scores indicate less adverse health measures and better overall health; Scores ≤ -2 or ≥ 2 represent statistically
significant differences from the Army average (0)
Variation by Installation
2
1
IHI 0
Army Average
-1
-2
IHI Scores*

Medical Readiness
Health Outcomes
Percent Not Medically Ready
Percent of Soldiers not medically ready within 72 hours based on the fol-
lowing medical readiness classifications: MRC3A (deficiencies resolvable
>72 hours, <31 days), MRC3B (deficiencies resolvable >30 days), and MRC4
(unknown status due to overdue dental/medical exams)
Data Source: Medical Operational Data System (MODS)
Chronic Disease
Percent of Soldiers with one or more of 6 diagnosed chronic conditions:
cardiovascular disease, cancer, arthritis, asthma, Chronic Obstructive
Pulmonary Disease (COPD), and diabetes
Data Source: MDR accessed via PH360
Behavioral Health Diagnoses
Percent of Soldiers with one or more of 7 diagnosed behavioral health
conditions: mood disorders, adjustment disorders, anxiety, personality
disorders, substance disorders, Post-Traumatic Stress Disorder (PTSD), and
psychoses
Data Source: MHS Data Repository (MDR), accessed via PH360
Injury Incidence
Number of new injuries diagnosed per 1,000 Soldiers
Data Source: Defense Medical Surveillance System (DMSS),
accessed via Public Health 360 (PH360)
Installation Health Index METRICS DESCRIPTION
Installation measures were adjusted by age
Installation measures were adjusted by gender and age
“No single measure can possibly capture the health of the nation.
A true measure would have to include indicators reflecting a broad
range of factors that together create a picture of the nation’s population.
—Institute of Medicine (IOM) State of the USA Health Indicators:
Letter Report, Dec 2008
”
Health Factors
Healthcare Delivery
Obesity
Percent of Soldiers with a body mass index (BMI)>30; BMI was determined by
height and weight measurements at the time of the Army Physical Fitness Test
(APFT)—medical records were used when APFT measures were unavailable
Data Source: Medical Readiness Assessment Tool (MRAT)
Preventable Hospital Admissions
Percent of hospital admissions among enrolled Soldiers considered prevent-
able per Agency for Healthcare Research and Quality (AHRQ) guidelines
Data Source: Command Management System (CMS)
Sleep Disorders
Percent of Soldiers with a diagnosed sleep disorder
Data Source: MRAT
Tobacco
Percent of Soldiers reporting tobacco use (smoking or smokeless tobacco
products) during dental exams
Data Source: Corporate Dental System (CDS)
Substance Abuse Disorders
Percent of Soldiers with a diagnosed substance abuse disorder
Data Source: MDR, accessed via PH360
Chlamydia Incidence
Number of new infections reported per 1,000 Soldiers
Data Source: Disease Reporting System internet (DRSi),
accessed via PH360
Installation measures were adjusted by gender and age

In 2010, the Army Public
Health Center (APHC) recog-
nized a need for actionable,
evidence-based indicators
of health within Army com-
munities, which could ideally
be tracked across installa-
tions with a user-friendly
dashboard tool. Although
the Army tracks a variety
of health and readiness metrics, a
comprehensive, prioritized list of
health outcome-focused measures
most relevant to Army public health
professionals did not exist. Available
measures were tracked in a multi-
tude of disparate and often non-in-
tuitive systems which complicated
community health assessment.
Subsequently, an APHC panel of
subject matter experts was formed,
identifying approximately 40 lead-
ing health indicators/metrics from
which a subset of key health-out-
come, demographic and morbidity
burden metrics were selected for an
inaugural ‘Community Health Status
Report’ released in 2013. Metrics were selected
based on a review of published health indicators
and health-related metrics commonly tracked both
nationally and within the Army, with some mea-
S P O T L I G H T
PUBLIC HEALTH 360
Installation Health Index PUBLIC HEALTH 360
sures adapted to be more relevant to the active
duty population. The report served as a template
for the resulting Public Health 360 (PH360), an
application which is part of the MEDCOM 360
application suite developed by the Patient Admin-
istration System and Biostatistics Activity (PASBA).
PH360 provides annual installation health summa-
ries and served as a resource for this report, sup-
porting 5 of the 10 core measures.
PH360 metric example
NSTITUTIONALAGILIT
PERSONALREADINESS
LEADERSHIPLEADERSHIP
INSTITUTIONALAGILITY
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
& Model
Army Culture:
Standards &
Values
Facilities
Policies &
Process
Training
Support
Unit &
Institutional
Training
Self-
Development
Goals &
Commitment
READINESS
CAC-enabled website: https://pasba.army.mil/MEDCOM360/Dashboard/Map/PH360
PH360 offers a viable platform from which to
incorporate the health indicators tracked for the
Health of the Force initiative. Not only are half
of the core measures derived from PH360 data,
but many of the additional metrics included in
this report are also part of the broader list of 40
metrics identified by the APHC panel for future
integration into PH360. Adding the additional
data summaries, and statistical analyses cov-
ered in this report to PH360 will enhance the
application and provide a user-friendly tool
for installations to access their information as
updates become available.

Community Health Promotion Council
THE ARMY’S FUTURE OPERATIONAL ENVIRONMENT
requires our leaders, Soldiers, Army Civilians and
Family Members to be resilient and sustain per-
sonal readiness. Personal readiness is an individ-
ual’s physical, psychological, social and spiritual
preparedness to achieve and sustain optimal
performance in supporting the Army mission.
Through a partnership with the G1-Army Resiliency
Directorate and the Army Public Health Center
(APHC), a coalition-building model of integration
was developed to meet the challenges of this
future environment.
Solutions to the Army’s unique challenges require
data-driven programming and decision making
at the installation level, bringing stakeholders
together to integrate and synchronize health
promotion and ready and resilient activities among
the tactical, medical, and garrison leadership. The
Community Health Promotion Coun-
cil (CHPC) provides a platform for this
sychronization. The CHPC provides
linkages from the Senior Command-
er down to individual units to directly
impact Soldiers and Families and
ensure the process is driven based on
identified issues and trends. Over the
years the key message in every Inspector General
report focused on Soldiers and Family Member
programs was that people didn’t even know what
was available to them. The Institute of Medicine
(IOM) report backs up this finding and reports that
failures in system capabilities are often a result
of how public health services are organized and
delivered across communities. Often the system-
atic errors are poor reporting and communication
of population health trends rather than technical
failures. These concerns led the Army to look at
the widespread need for a strong and integrated
system where leaders of all agencies on an installa-
tion meet regularly to look at gaps and overlaps of
support services on an installation, to include what
is and is not working to meet the intended out-
come the program was designed to achieve.
The essential standard for the CHPC is that it is
chaired at the highest level of leadership on an
Army installation (the Senior Commander (SC) or
the Senior Responsible Officer (SRO)). The SC or
SRO champions and leads the CHPC, providing the
authority to influence the programs, policies, and
environments that affect the installation’s health.
The CHPC is directed by AR 600-63, Army Health
Promotion and centrally managed by a team of
experts at APHC that trains and provides contin-
uous technical guidance to all Health Promotion
Officers (HPOs) and Health Promotion Program
THE COMMUNITY HEALTH
PROMOTION COUNCIL (CHPC):
The Strategic Integrating Platform at the Installation
“...promote and safeguard the morale, the physical
well-being, and the general welfare of the officers and
enlisted persons under their command or charge.”
—AR 600-20
Installation Health Index COMMUNITY HEALTH PROMOTION COUNCIL
Assistants (HPPAs) at Army installations, assigned
as special staff to the Senior Commander. Their
full-time responsibility is to facilitate the CHPC and
ensure it is consistent with the Ready and Resilient
Campaign (R2C) which directs Senior Commanders
to establish CHPCs to synchronize R2C activities.
The CHPC also supports AR 600-20, which requires
Commanders to: “promote and safeguard the
morale, the physical well-being, and the general
welfare of the officers and enlisted persons under
their command or charge.” This coordinated and
integrated council process ultimately elevates
installation-level council findings into the overall
Army Health Promotion Council process chaired by
the Vice Chief of Staff of the Army. R2 Governance
facilitates communication and provides the oppor-
tunity to evaluate and implement change rapidly
throughout the Army to increase and sustain per-
sonal and unit readiness and resilience.
Integration and synchronization within the Ready and Resilient/System for Health/
Public Health System is the first and most critical step in improving and safeguarding
the Readiness, Resiliency, and Health of the Force at the installation level.
Community Health Promotion Council
Medical
Treatment
Facility
Leadership
Faith
Institutions Neighborhood
Organizations
ADCO/ASAP
Schools
EMS
Garrison
Leadership
Elected
Ofﬁcials
Public Affairs
Family
Advocacy
Master
Planners
Tenant Unit
Leadership
Dentists
Mental Health
MWR,
Fitness Centers
Tactical
Leadership
Transit
Senior
Commander
Public Health
Department
on and off
installation
AAFES/DECA
MP’s/Law
Enforcement
Community
Health
Promotion
Council
Fire Department
on and off
installation
Safety
Employers

Medical Readiness MEDICAL READINESS
MEDICAL READINESS
Medical readiness is a priority for the U.S. Army; it
can have a significant impact on mission comple-
tion. Soldiers with medical deficiencies that are
not resolvable within 72 hours are a greater cause
for concern, and are assigned a medical readiness
classification (MRC) of 3 or 4. Approximately 17% of
AD Soldiers were considered not medically ready
within 72 hours in 2014. The proportion not medi-
cally ready ranged from 12% to 23% across installa-
tions. Close to half were classified as MRC3B, which
is indicative of deficiencies requiring more than 30
days to resolve. One-third of those not medically
ready were classified as MRC4 due to overdue den-
tal and medical exams. The proportion not ready
was correlated with age, ranging from roughly 15%
for Soldiers under 25 years to 24% for Soldiers 45
years and older.
31 HEALTH OF THE FORCE MEDICAL READINESS 32
TOTAL
45+
MRC3A MRC3B MRC4
35–45
25–35
<25
0.0 5.0 10.0 15.0 20.0 25.0
Percent Not Medically Ready by Medical Readiness Classification
(MRC) and Age,AD Soldiers, 2014
MRC3A: deficiencies resolvable >72 hours and <31 days; MRC3B: deficiencies resolvable >30 days; MRC4:
unknown status due to overdue dental/medical exams
“If we don’t get our arms around the non-deployable population, and the big-
gest population is the MNR [medically not ready] population, we’re going to
have a significant problem manning our units to get them downrange. The
Soldier is the center of our formations, so if the Soldier is not ready to go,
then the unit is not ready to go.”
—MG Brian Lein l
Commanding General, MRMC
Overall, 17% of Soldiers were
classified as not medically ready.
Non-readiness ranged from
12% to 23% across installations.
17%

Medical Readiness MEDICAL READINESS
Soldiers are part of a very elite group—less than 1% of the U.S. population earns the
privilege of military service. Being a Soldier and a member of the Profession of Arms requires
intensive preparation, specialized education and continuous learning, and skill development.
Unfortunately, approximately 1,400 Soldiers become medically non-available each month,
limiting the ability of the Army to accomplish its missions.
The Medical Readiness
Assessment Tool (MRAT) is
a set of electronic decision
support and screening tools
developed by the Innovative
Clinical Analytics (ICA) team
at the OTSG. The MRAT
leverages best practices
from programs in civilian
health systems shown to improve the health and
readiness of our Soldiers.
The primary objective of the MRAT is to enable
identification and management of Soldiers with
risk factors affecting future medical readiness at
an earlier point than was previously feasible. The
MRAT uses a regression model-based approach to
project the risk of a medically non-available (MNA)
status in the following 12 months.
The MRAT provides both clinical and leader tools
to support medical and command teams in pro-
actively identifying and supporting Soldiers at
risk for becoming MNA. Commanders can use
the readiness related graphs to identify and share
best practices from units with lower risk levels. The
MRAT assists clinicians in carrying out the Com-
mander’s intent to improve unit readiness and
health at the individual level. The MRAT screening
tool structure and sorting functions support pro-
viders by guiding them to the most at-risk Soldiers
and facilitating holistic patient insight.
MRAT access is granted based on role and users
must complete self-paced or in-person training
prior to use to ensure accurate interpretation and
appropriate use of displayed information. For
more information on the MRAT, please contact the
Innovative Clinical Analytics Group at the Office
of The Surgeon General, Falls Church, VA at 703-
681-4563 or at usarmy.ncr.hqda-otsg.mesg.inno-
vative-clinical-analytics@mail.mil. Information may
also be located at the MRAT Milbook site:
https://www.milsuite.mil/book/groups/medi-
cal-readiness-assessment-tool-mrat
Source: MRAT Handbook: Medical Readiness Assessment Tool How-To Use Manual. 20 March 2015. Innovative
Clinical Analytics, Operational Research and Modeling Cell, Office of The Surgeon General, Falls Church, VA.
S P O T L I G H T
MEDICAL READINESS ASSESSMENT TOOL
NSTITUTIONALAGILIT
LEADERSHIP
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
& Model
Army Culture:
Standards &
Values
Facilities
Policies &
Process
Training
Support
Unit &
Institutional
Training
Self-
Development
Goals &
Commitment
READINESS
PERSONALREADINESS
MEDICAL READINESS 34

All Injury Overuse Injury
2007
500
0
1,000
1,500
2008 2009 2010 2011 2012 2013 2014
Calendar Year
RatePer1,000Soldiers
1,289.2
1,352.9 1,348.9 1,371.3
1,330.7 1,347.9 1,332.0
1,294.1
697.1 716.6 710.3 712.4 689.9 703.0 709.8 689.8
Annual Injury Rates,AD Soldiers, 2007–2014
INJURYHealth Outcomes
HEALTH OUTCOMES 36
Women Men
3,000 2,000
Rate per 1,000 Rate per 1,000
1,000 0
Total
45+
35–44
25–34
<25
0 1,000 2,000 3,000
1,236.5
2,087.9
1,617.1
1,229.8
997.0
1,640.1
2,649.3
1,964.1
1,507.2
1,552.9
Rate of Injuries by Gender and Age,AD Soldiers, 2014
Injury
Injury is a significant contributor to the Army’s
healthcare burden, impacting medical readiness
and Soldier health. Over one million medical
encounters and roughly 10 million days of limited
duty occur annually as a result of injuries and inju-
ry related musculoskeletal conditions, affecting
close to 300,000 Soldiers or roughly 55% per year.
Additionally, musculoskeletal injuries account for
76% of the medical non-deployable population.
Among the Active Duty Soldiers evaluated,
injuries were common with approximately 1,300
new injuries diagnosed per 1,000 Soldiers in 2014;
the high rate reflects multiple injuries occurring
among affected Soldiers. Rates ranged from 1,062
to 1,648 per 1,000 across the installations. Roughly
half of all injuries were related to overuse. Injury
rates were 1.2 to 1.5 times higher among women
than men, depending on the age group rates.
Rates were substantially higher among Soldiers
45 years and older. Injury trends varied by age.
While rates have been increasing for Soldiers 35
years and older, rates have been declining for
younger Soldiers. Overall rates have remained
fairly stable. Leading causes of injury as indicated
on medical records were overexertion (27%), falls
(15%), and being struck by or against an object
(15%).
Overall, 55% of Soldiers were diagnosed with an
injury. Roughly 1,295 new injuries were diagnosed
per 1,000 Soldiers.
Injury rates ranged from 1,062 to 1,648 per 1,000
across installations.
1,295

INJURY
2007
<25
25–34
AGE
35–44
45+
1,000
1,200
1,400
1,600
1,800
2,000
2,200
2,400
2008 2009 2010 2011 2012 2013 2014
1,075.4
1,269.3
1,661.5
2,167.7
1,150.8
1,304.5
1,620.4
1,987.0
1,176.2
1,339.3
1,609.7
1,987.7
1,196.9
1,309.5
1,563.2
1,915.9
1,284.6
1,326.0
1,561.2
1,858.2
1,313.2
1,296.5
1,476.1
1,686.8
1,327.3
1,302.8
1,453.5
1,690.6
1,293.2
1,227.0
1,333.5
1,582.1
Rateper1,000person-years
Annual Injury Rates by Age,AD Soldiers, 2007–2014
Health Outcomes
HEALTH OUTCOMES 38
Top 5 Causes of Unintentional Injury,AD Soldiers, 2014
Injuries account for approximately:
»» 50% of injuries are associated with physical training and sports
»» 76% of Soldiers non-medically ready to deploy have musculoskeletal injuries (MSKI)
that prevent deployment
0
5
10
15
20
25
30
PercentageofUnintentionalInjuires
27.4%
15.2% 15.2%
9.0%
6.4%
O
verexertion
Fall
Struck
by,against
M
otorVehicle
Traffic
C
ut/pierce
Percentages based on cause coded outpatient records
DEATHS
DISABILITES
OUTPATIENT
MEDICAL
VISITS
1/5
2/3
1/4
“Young men and women coming in theArmy today are not as fit
or as skeletally sound…even in basic training,before we load
the soldier with the gear that eventually they will have to learn
to bear,we have these same kind of musculoskeletal injuries.”
–GEN Martin Dempsey
2011 testimony to SenateAppropriations Committee

2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
0
500
1000
1500
2000
2500
3000
3500
4000
Calendar Year
RatePer1,000PY
Lower extremity overuse injuries
All injuries
Implementation
of standardized PT
INJURYHealth Outcomes
S P O T L I G H T
Physical training (PT) is necessary to develop and maintain the fitness required to
accomplish military missions, but is also known to cause injury. In 2003, the Army
evaluated a new standardized physical training program designed to enhance
fitness while minimizing injuries through avoidance of overtraining. An evaluation
group implemented the new standardized program and a control group con-
ducted traditional PT (running, calisthenics, push-ups, and sit-ups). After 9 weeks
of basic combat training (BCT), the evaluation group had fewer injuries and a
higher APFT pass rate. In 2004, the new standardized PT program was mandated
for all BCT units across the Army. It was also incorporated into Army physical train-
ing doctrine. From 2003 to 2013, a 46% decrease in all injuries and a 54% decrease
in lower extremity overuse injuries among Army trainees was observed.
PHYSICAL TRAINING DURING
BASIC COMBAT TRAINING
U.S.Army Trainee Injury and Lower Extremity Overuse Injury Rates,
2000–2013
INSTITUTIONALAGILITYINSTITUTIONALAGILITY
LEADERSHIP
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
& Model
Army Culture:
Standards &
Values
Facilities
Policies &
Process
Training
Support
Unit &
Institutional
Training
Self-
Development
Goals &
Commitment
READINESS
PERSONALREADINESS
HEALTH OUTCOMES 40
It is a common belief that athletic shoes should be selected
based on foot shape. Most athletic shoe companies manu-
facture a variety of “motion control,” “cushioned,” and “sta-
bility” shoes aimed to address varying arch heights. In 2007,
studies were conducted in Army, Marine, and Air Force basic
training to determine if injury risk was lower when athletic
shoes were selected based on foot shape. A group
of basic trainees were provided shoes based
on arch height (the experimental group), while
another group received a stability shoe regard-
less of arch height (the control group). Results of
the three investigations were the same: assign-
ing athletic shoes on the basis of foot arch height
did not reduce injuries.
SHOE TYPE
DID YOU KNOW?
Elements of standardized PT program
implemented to prevent overtraining
and avoid injury*:
— Reduced total miles run
— Conducted distance runs by ability groups
— Added speed drills
— Executed warm-up exercises instead of
pre-exercise stretching
— Progressed training amount and
intensity gradually
— Provided wider variety of exercises
* These elements are now contained in Field
Manual 7-22: Army Physical Readiness Training
(Department of the Army, October 2012)

BEHAVIORAL HEALTH
Behavioral Health
The stressors of military life can have a profound
impact on the psychological well-being of Soldiers
and Families. Behavioral health (BH) disorders
such as depression, Posttraumatic Stress Disor-
der (PTSD), and substance use are risk factors
for a number of negative outcomes for Soldiers,
including being medically not ready for duty, early
discharge from the Army, and suicidal behavior.
Behavioral health disorders also result in a substan-
tial healthcare burden. Among the roughly 80,000
Soldiers seeking care for BH conditions each year,
over one million medical encounters and 80,000
hospital admission days occur.
An examination of BH diagnoses for mood disor-
ders, PTSD or other anxiety disorders, adjustment
disorders, substance use disorders, personality
disorders, or psychosis indicated that approximate-
ly 15% of Active Duty Soldiers had one or more
conditions diagnosed in 2014, with adjustment
disorders being the most common. The proportion
affected ranged from 9% to 20% across installa-
tions. Conditions were generally more prevalent
among female Soldiers, affecting 23% of women as
compared to 14% of men. The proportion affected
increased with age.
Health Outcomes
HEALTH OUTCOMES 42
Percent Diagnosed with Selected Behavioral Health Disorders by
Gender and Age,AD Soldiers, 2014
Women Men
Percent Percent
05 510 1015 1520 2025 2530 3035 35
Total
45+
35–44
25–34
<25
0
13.5%
17.4%
18.2%
14.6%
9.3%
22.7%
29.1%
27.3%
23.6%
18.9%
diagnosed with a behavioral
health disorder.
Behavioral health disorder rates
ranged from 9% to 20% across
installations.
15%
MenWomen
PercentPercent
00510152025 5 10 15 20 25
Psychosis0.3
Personality Disorder0.6%
0.2%
0.2%
Substance Disorder1.3% 2.0%
PTSD3.5% 3.0%
Any Mood Disorder10.4% 4.7%
Adjustment Disorder13.8% 7.4%
Any BH condition22.7% 13.5%
Other Anxiety Disorder8.9% 5.0%
Percent Diagnosed with Behavioral Health Disorders by Gender and
Diagnosis Category,AD Soldiers, 2014

BEHAVIORAL HEALTH
2007
Any BH Disorder
Adjustment Disorder
Mood Disorder
OtherAnxietyDisorder
PTSD
Substance Disorder
Personality Disorder
Psychosis
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
2008 2009 2010 2011 2012 2013 2014
14.7
8.3
5.5
5.6
3.1
1.9
0.3
0.2
15.3
9.2
5.7
5.4
3.3
2.1
0.3
0.2
15.9
10.0
6.0
5.4
3.5
2.3
0.4
14.5
8.7
5.6
4.5
3.0
2.3
0.4
13.6
7.9
5.3
3.9
2.6
2.5
0.4
12.5
7.0
4.9
3.3
2.5
2.5
0.4
10.9
5.9
4.1
2.7
2.2
2.2
0.4
9.4
4.7
3.5
2.0
1.5
2.0
0.5
0.30.20.20.20.20.1
Percent
Percent Diagnosed with Behavioral Health Disorders by Diagnosis
Category,AD Soldiers, 2007–2014
Health Outcomes
HEALTH OUTCOMES 44
S P O T L I G H T
S P O T L I G H T
Family readiness is an integral part of Soldier readiness. Although measures of
Family health are not presented in this edition of Health of the Force, the Army’s
Comprehensive Behavioral Health System of Care incorporates initiatives to
improve the way behavioral health needs of Family members are addressed
and treated. Child and Family Behavioral Health System (CAFBHS) is the Army’s
comprehensive behavioral health (BH) model designed to support the needs of
Army Children and Families by aligning and collaborating with Army Medical
Homes (AMHs) and other Family Member oriented clinics. CAFBHS is a transi-
tion from legacy Child and Family BH programs into a consultative, integrated,
collaborative care model in support of AMHs. The program utilizes best practices
and recognizes BH functioning as integral to overall health and well being, and is based on standardized
evidence-based training for providers, treatment, and follow-up. The CAFBHS School Behavioral Health
(SBH) embeds BH providers in on-post schools to provide services in a child’s academic environment,
improving access, enhancing resiliency and reducing stigma. Today, SBH operates in 47 schools on 10
installations and will grow over the next two years to nearly 100 schools on 18 installations.
To more effectively and efficiently meet comprehensive behavioral healthcare
needs, in JAN 2015, Army Medical Command (MEDCOM) directed medical
treatment facilities to establish and realign Intensive Outpatient Programs (IOPs).
IOPs provide an intermediate level of behavioral health care, reduce the need for
hospitalization, and result in the same or similar outcomes in treatment efficacy
as inpatient treatment. Continuity of care is also enhanced, as promoted by
the Substance and Mental Health Society of America’s (SAMHSA) endorsement
of IOPs as part of a continuum of care that provides robust, multidimensional
treatment options. During the IOP experience patients live in their natural envi-
ronment during treatment and are able to apply learning and relapse prevention
training and address critical concerns in a supportive environment. The ultimate goal is for Soldiers to
apply what they have learned to real-world scenarios outside of the treatment environment.
CHILD AND FAMILY BEHAVIORAL HEALTH
SYSTEM (CAFBHS)
INTENSIVE OUTPATIENT PROGRAM (IOP)
LEADERSHIP
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
& Model
Army Culture:
Standards &
Values
Facilities
Policies &
Process
Training
Support
Unit &
Institutional
Training
Self-
Development
Goals &
Commitment
READINESS
PERSONALREADINESS
LEADERSHIP
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
& Model
Army Culture:
Standards &
Values
Facilities
Policies &
Process
Training
Support
Unit &
Institutional
Training
Self-
Development
Goals &
Commitment
READINESS
PERSONALREADINESS
“No nation has ever survived, and no nation ever will
survive, whose people are not physically, mentally,
and morally fit for survival.”
—Studies in Citizenship For Recruits - 1922

Health Outcomes
CHRONIC DISEASE
Chronic Disease
Chronic disease exacts a toll on one’s quality of
life, requiring sustained clinical management to
avoid severe health outcomes or complications.
The six chronic conditions assessed (cardiovas-
cular conditions, cancer, asthma, arthritis, chronic
obstructive pulmonary disease (COPD), and dia-
betes) were ranked as one of the top 20 leading
indicators of health by the Institute of Medicine.
Among Active Duty Soldiers, chronic medical con-
ditions can also impact medical readiness, since
they may decrease Soldiers’ ability to support
more physically demanding mission requirements
or to deploy to remote locations where healthcare
resources may be more limited. Approximately
14% of Active Duty Soldiers were diagnosed with
one or more of these conditions in 2014. The pro-
portion affected ranged from 12% to 21% across
installations. Cardiovascular conditions comprised
the majority of diagnoses, followed by arthritis,
asthma, and COPD. Chronic disease strongly cor-
related with age, with roughly 45% of Soldiers 45
years and older being diagnosed. Female Soldiers
also experienced higher rates (18% overall as com-
pared to 14% of males).
HEALTH OUTCOMES 46
Women Men
60 40
Percent Percent
20 0
Total
45+
35–44
25–34
<25
0 20 40 60
13.5%17.8%
43.6%50.2%
25.9%30.7%
11.3%16.5%
6.0%9.7%
Percent Diagnosed with Selected Chronic Diseases by Gender and
Age,AD Soldiers, 2014
diagnosed with a chronic condition.
Chronic disease rates ranged from
12% to 21% across the installations.
14%
“Army Medicine is transforming from a healthcare system to a system for health.
Army Medicine will consistently deliver evidenced-based value added services to our
beneficiaries,improve existing healthcare programs and services,and develop new
processes and initiatives to improve the health of the populations entrusted to our
care. We will engage people where they live,work,and play (i.e.,the Lifespace) in
addition to traditional patient care settings,to affect the determinants of health and
improveArmy readiness.”
–LTG Patricia Horoho
43rd Surgeon General of the United StatesArmy

CHRONIC DISEASE
2007
Any
Cardiovascular
Arthritis
Asthma
COPD
Cancer
Diabetes
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
2008 2009 2010 2011 2012 2013 2014
14.1
9.4
2.7
1.9
1.5
0.4
0.4
14.6
9.6
2.7
2.0
1.8
0.4
0.4
14.9
9.7
2.7
2.2
2.0
0.4
0.5
14.4
9.0
2.5
2.2
2.3
0.4
0.4
13.8
8.3
2.2
2.2
2.5
0.4
0.4
12.8
7.6
1.9
2.2
2.4
0.4
0.4
12.1
7.1
1.8
2.0
2.4
0.3
0.3
11.8
6.8
1.7
2.0
2.3
0.3
0.3
Percent
Percent Diagnosed with Chronic Disease by Diagnosis Category,
AD Soldiers, 2014
Health Outcomes
The Institute of Medicine (IOM) identified the
6 chronic conditions measured collectively above
as one of 20 key indicators of health.
Source: Institute of Medicine (IOM) State of the USA Health Indicators: Letter Report, Dec 2008
HEALTH OUTCOMES 48
S P O T L I G H T
The leading preventable causes of death in Amer-
ica have been called lifestyle mediated diseases—
meaning individual behaviors contribute greatly
to the health of our nation. As part of the shift
from a healthcare treatment system to a System
for Health, the Army Surgeon General directed
implementation of 37 Army Wellness Center (AWC)
facilities across the Army enterprise to a defined
standard of operation for a consistent patient
experience. There are currently 26 AWCs in the
communities where people live, work, and play—in
their Life-space.
The AWCs are an extension of the Patient Cen-
tered Medical Home, delivering standardized
evidence-based primary prevention programs
designed to promote enhanced and sustained
healthy lifestyles, thus improving the overall
well-being of the Army Family. Abundant evidence
suggests that management of sleep, activity,
nutrition, stress, and tobacco use reduces disease,
improves overall health, resilience, and readiness,
and reduces long term healthcare costs. AWCs
provide tailored health assessments with a one-on-
one individualized health and wellness plan, health
education, and specific health coaching to reduce
disease risk factors and promote healthy behav-
iors. Through collaborative and synchronized
efforts, AWCs represent an actionable platform
supporting the Ready and Resilient Campaign, the
Performance Triad, the Healthy Base Initiative, and
Comprehensive Soldier and Family Fitness across
the Army.
AWCs utilize advanced tech-
nology to measure the four
components of physical
fitness: cardiorespiratory
function, body composi-
tion, muscular fitness, and
flexibility). This service
is part of a beneficiary’s
medical benefits; a similar
assessment and follow-on edu-
cation costs in excess of $3000 in the U.S. health-
care system.
Data currently collected across the enterprise
indicates statistically significant improvements in
health behaviors, aerobic capacity, decreased body
fat, and decreased body mass index for those ben-
eficiaries who use the Army Wellness Centers.
ARMY WELLNESS CENTERS
LEADERSHIP
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
& Model
Army Culture:
Standards &
Values
Facilities
Policies &
Process
Training
Support
Unit &
Institutional
Training
Self-
Development
Goals &
Commitment
READINESS
PERSONALREADINESS
“Army Wellness Centers, the Ready and
Resilient Campaign and the Performance
Triad will improve health and help prevent
disease and injury…We need to challenge
how we look at wellness from different
perspectives. If [Soldiers] know why they
should do it, they will change behaviors.”
—LtGen Patricia D. Horoho
43rd U.S. Army Surgeon General and Commander
U.S. Army Medical Command

Health Factors OBESITY
Obesity
Obesity has a noticeable negative impact on
health, increasing the risk of heart disease, type 2
diabetes, cancer, stroke, and high blood pressure.
It is also a leading factor in preventable death.
Obesity has become increasingly prevalent in
the U.S., more than doubling since 1990 to affect
approximately 29% of adults in 2013. Because the
Army has strict physical fitness requirements for
Soldiers, obesity is less common than it is in the
general U.S. population.
Prevalence of obesity was determined by the body
mass index (BMI) calculated during a Soldier’s
Army Physical Fitness Test (APFT). Despite Army
Body Composition Standards, roughly 13% of Sol-
diers were obese in 2014. The proportion classified
as obese ranged from 9% to 18% across installa-
tions. Obesity rates were higher among men (13%)
compared to women (8%). Age strongly influenced
rates of obesity, with higher levels observed with
increasing age.
Women Men
Percent Percent
0 0 5 10 15 20 252530 20 15 10 5 30
Total
45+
35–44
25–34
<25
7.9
14.5
14.3
8.3
4.0
13.3
22.2
24.2
14.1
6.2
classified as obese.
Obesity ranged from 9% to 18%
13%
Percent Classified as Obese by Gender and Age,AD Soldiers, 2014
“The obese service members in the brigade inAfghanistan
were 40% more likely to experience an injury than those
with a healthy weight,and slower runners were 49% more
likely to be injured.”
—Mission Readiness Report
“Retreat is Not an Option:Healthier School Meals Protect our Children and Our Country.”- Page 14
HEALTH FACTORS 50

DC
T X
C A
M T
A Z
N V
C O
I D
N M
O R
K S
U T
W Y
S D
I L
N E
I A
M N
O K
F L
N D
A L
W A
M O
G A
W I
A R
L A
P A
N C
N Y
K Y
I N
M S
T N
M I
V A
O H
S C
M E
W V
M I
V T
N H
N J
M D
M A
C T
DE
R I
A K
H I
After standardizing Army rates for
comparison with rates reported in
the U.S. general population, which
has a much higher proportion of
older adults, the Army had sub-
stantially lower rates. Standardized
Army rates ranged from 7 to 24%
across installations, while those
reported nationally ranged from
20 to 34%. No significant correla-
tion between installation and state
rates was observed.
Health Factors OBESITY
HEALTH FACTORS 52
≤25.4%
25.5%–27.2%
27.3%–29.8%
29.9%–31.3%
≥31.4%
% of Active Duty Soldiers
classified as obese
(% standardized to U.S. population)
% of U.S. adults
classified as obese
Geographic Comparison of Obesity: Army Installation and U.S. State Rates*
≤13.3%
13.3%–14.5%
14.5%–16.5%
16.5%–18.0%
≥18.0%–24.4%
S P O T L I G H T
Have you ever wondered about the food choices
on your installation, what choices your vending
machines offer, or if sidewalks connect on your
installation so you can take a safe walk on your
lunch break or after work? How do you create an
environment where the healthy choice is the easy
choice…and likely?
Leading public health organizations, including the
World Health Organization, the Institute of Med-
icine, the International Obesity Task Force, and
the Centers for Disease Control and Prevention
have identified environmental and policy interven-
tions as the most promising strategies for creating
population-wide improvements in health behaviors
to include healthy eating, physical activity, and
tobacco use.
The Army Public Health Center (APHC), in part-
nership with Operation Live Well and the Healthy
Base Initiative, developed a toolkit, Creating
Active Communities and Healthy Environments
(CACHE), as a strategic initiative to address chronic
disease prevention in the military by transform-
ing installations into healthy living communities.
CACHE consists of three tools: the Promoting
Active Communities (PAC) assessment, the Mil-
itary Nutrition Environmental Assessment Tool
(m-NEAT), and the Quantitative Indicators of
Tobacco Systems (QITS). These
tools assess an installation’s envi-
ronment and policies related to the
promotion and support of physical
activity, healthy eating, and tobac-
co-free living. Assessment results
define improvement areas and
guide implementation of policies
and environmental changes around
healthy living strategies.
The Community Health
Promotion Council (CHPC),
chaired by the Senior Com-
mander on the installation—
and comprised of the Garri-
son and MTF Commanders,
Master Planners, AAFES,
DeCA, leads from all service
agencies, tenant unit commanders, and other ad
hoc members—then work together to use CACHE
results and identify target areas that the council
will address to improve the built/healthy environ-
ment on the installation via an action plan.
Using the CACHE to spark intentional environmen-
tal change demonstrates an installation’s commit-
ment to wellness, and increases awareness of the
community’s vision and assets related to healthy
living. Results can be compared to installations
across the enterprise, and installations can learn
from each other where successful change has
occurred. The toolkit enhances collaboration on
the installation as CHPC members develop new
partnerships and enhance existing partnerships
as a result of working together to complete the
assessment. Finally, a key and essential benefit of
using the CACHE is the opportunity for installa-
tions to monitor their progress and show positive
change over time.
CREATING ACTIVE COMMUNITIES
AND HEALTHY ENVIRONMENTS (CACHE)
Where people live, work, and play affects their health!
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
Model
Army Culture:
Standards
Values
Facilities
Policies
Process
Training
Support
Unit
Institutional
Training
Self-
Development
Goals
Commitment
READINESS
PERSONALREADINESS

Overall, 32% of Soldiers reported
tobacco use.
Tobacco use ranged from 13% to
32%
Health Factors
Tobacco
Tobacco use can cause a wide variety of negative
health outcomes, including organ damage, respi-
ratory disease, heart disease, stroke, cancer, and
premature death. Smokers have also been shown
to have an increased risk for injuries, and smoking
inhibits wound healing. U.S. prevention campaigns
have had some success in lowering smoking rates
over the years, with a 36% decrease in national rates
since 1990, reaching a low of 19% in 2013. The Army,
too, has taken a strong stance to reduce tobacco
use with health promotion efforts such as the recent
launch of tobacco-free campus campaigns.
Smoking rates as determined from Soldier dental
exams revealed that 23% of Active Duty Soldiers
smoked exclusively, 13% used smokeless tobac-
co exclusively and 4% used both, bringing the
total tobacco usage to roughly 32%. Tobacco
use ranged from 13 to 40% across installations.
Tobacco use among AD Soldiers is most common
among males; usage by men was more than twice
that of women.
TOBACCO
Women Men
40 30 20
Percent Percent
10 0
Total
45+
35–44
25–34
25
0 10 20 30 40
15.0
14.4
12.7
16.7
14.3
34.5
21.3
30.6
36.9
35.4
Percent Reporting Tobacco Use by Gender and Age,AD Soldiers, 2014
“This year alone, nearly one-half million adults will still die
prematurely because of smoking. Annually, the total econom-
ic costs due to tobacco are now over $289 billion. And if we
continue on our current trajectory, 5.6 million children alive
today who are younger than 18 years of age will die prema-
turely as a result of smoking.”
—Kathleen Sebelius,
Secretary of Health and Human Services (2014)

Health Factors
TOBACCO
HEALTH FACTORS 56
S P O T L I G H T
obacco use and smoking-related diseases
are the leading causes of devastating, yet
preventable and reversible health-related
diseases in the United States. The Army Medical
Command (MEDCOM) continues its commitment to
beneficiaries as a System for Health in support of the
2020 Department of Defense (DOD) goal for creating
tobacco-free workforce and installations.
In May 2015, TSG announced her intent and plan to
promote Tobacco-Free Living (TFL) workforces and
Tobacco-Free Medical Campuses (TFMC) via OPERA-
TIONS ORDER 15-48 (Medical Command (MEDCOM)
Tobacco-Free Living). TFL and TFMCs provide safe
environments for patients to receive their care. TFL
includes tobacco prevention, incremental tobacco
reduction, and control. TFL will be implemented
across the enterprise in order to create a tobacco-free
community that promotes the overall health of
military personnel, Family members, retirees, and all
employees on MEDCOM campuses. The overarching
goal of the MEDCOM TFL OPORD is to improve the
health, wellness and productivity of the Army Family.
OPORD 15-48 specifically
states that no MEDCOM
personnel will use any tobacco
products during the duty day.
This includes military, civilians,
contractors and local national
employees. It also calls for the removal of desig-
nated tobacco use areas, smoking areas or smoking
shelters and states that personnel, persons seeking
health care, and visitors are prohibited from using
any form of tobacco on or within the medical cam-
pus, as established by the AR 600-63, 16 Apr 15.
An evaluation of the first tobacco-free medical cam-
pus policy found a significant reduction in MEDCOM
employee second hand smoke exposure and a sig-
nificant increase in employee satisfaction with their
workplace tobacco policy. Through the implementa-
tion of such policies across the enterprise, MEDCOM
is leading the way to a healthier workforce and Army.
n estimated 23% of the AD Soldiers evalu-
ated for this report were identified as current
smokers during dental visits. This estimate
is slightly lower than that reported on the 2011 DOD
Health-related Behaviors Survey administered to AD
members, from which roughly 27% of Soldiers were
determined to be current smokers.
National prevalence estimates are lower, with 19%
of the general adult population classified as current
smokers. Published studies also confirm higher rates
among the U.S. military in comparison to the U.S.
general population.
• A CDC assessment of National Health Interview
Surveys collected from 2007 to 2010 revealed that
cigarette smoking prevalence was higher among
people currently serving in the military than
among the civilian population.
• The Institute of Medicine (IOM), which has pub-
lished guidance for tobacco cessation in military
and veteran populations, also reports that ciga-
rette smoking prevalence is even higher among
military personnel who have been deployed, with
smoking rates up to 50% higher among veterans
returning from Afghanistan and Iraq.
MEDCOM TOBACCO-FREE LIVING (TFL)
WORKFORCES AND TOBACCO-FREE
MEDICAL CAMPUSES
TOBACCO STATISTICS
References:
CDC http://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html
IOM http://iom.nationalacademies.org/Reports/2009/MilitarySmokingCessation.aspx
DoD HRB http://prevent.org//data/files/actiontoquit/final%202011%20hrb%20active%20duty%20survey%20report-release.pdf
A
T
PERSONALREADINESS
LEADERSHIP
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
Model
Army Culture:
Standards
Values
Facilities
Policies
Process
Training
Support
Unit
Institutional
Training
Self-
Development
Goals
Commitment
READINESS
PERSONALREADINESS
Tobacco-free worksites reduce tobacco use of employ-
ees. The more stringent policies show the greatest
impact on employees’ tobacco habits. Policies that have
been in place for longer periods of time reduce tobacco
use among employees further.
• Tobacco use is costly for the DOD; one study estimates
that the Department spends an extra $564 million
annually on medical care as a result of tobacco use.
• There is no safe level of exposure to secondhand
smoke (SHS).
• The negative health effects of SHS exposure include
lung cancer, lower respiratory tract infections, asthma,
cardiovascular disease, and nasal irritation.
Reference:
Dall TM, Zhang Y, Chen YJ, et al. Cost associated with being
overweight and with obesity, high alcohol consumption, and
tobacco use within the military health system’s TRICARE
prime-enrolled population. Am J Health Promot 2007 Nov-
Dec;22(2):120-139.
Lee JT, Glantz SA, Millett C/ (2011). Effect of smoke-free
legislation on adult smoking behaviour in England in the 18
months following implementation. 2011; e20933
Callinan JE, Clarke A, Doherty K, Kelleher C. Legislative
smoking bans for reducing exposure, smoking prevalence and
tobacco consumption. Cochrane Database of Syst Rev 2010
Apr14;(4):CD005992.
Bauer JE, Hyland A, Li Q, Steger C, et al. A longitudinal
assessment of the impact of smoke-free worksite policies on
tobacco use. Am J Public Health 2005 Jun;95(6):1024–1029.
Hopkins DP, Razi S, Leeks KD, et al. Smokefree policies to
reduce tobacco use: A systematic review. Am J Prev Med
2010 Feb;38(2 Suppl):S275-S289.
Pirkle JL, Bernert JT, Caudill SP, Sosnoff CS, Pechacek,TF.
Trends in the exposure of nonsmokers in the US population
to secondhand smoke: 1988-2002. Environmental Health
Perspectives, 2006; 853-858.
Pickett MS, Schober SE, Brody DJ, et al. Smoke-free laws and
secondhand smoke exposure in US non-smoking adults, 1999
2002. Tob Control 2006 Aug;15(4):302-307.
TOBACCO-FREE WORKSITES
“I, for one, am happy because I don’t have to be exposed to that every
day. I don’t go home with my clothes smelling like cigarettes and that
sort of thing.”
—MEDCOM employee following the implementation of a tobacco free medical campus policy

Health Factors
Sleep Disorders
Sleep is critical in achieving optimal physical,
mental, and emotional health, but the demands
of one’s job often make it difficult to get sufficient
sleep. In training and on the battlefield, inade-
quate sleep impairs many abilities that are essen-
tial to the mission, including detecting and appro-
priately determining threat levels and coordinating
squad tactics. Getting optimal sleep starts with
learning and practicing good sleep habits. There
are many ways in which leaders and Soldiers can
eliminate sleep distractors and practice proper
sleep hygiene to ensure that optimal, healthy
sleep is achieved.
Approximately 10% of AD Soldiers had a diag-
nosed sleep disorder in 2014. The proportion
affected ranged from 5% to 14% across installa-
tions. Rates were higher among men as compared
to women and increased for both genders with
increasing age. For example, rates were almost
5 times higher for women 45 and older than for
women under 25; likewise, rates were roughly 8
times higher for men 45 and older compared to
men under 25.
SLEEP DISORDERS
HEALTH FACTORS 58
Women Men
40 30 20
Percent Percent
10 0
Total
45+
35–44
25–34
25
0 10 20 30 40
8.7
23.8
15.9
8.0
4.8
10.6
32.3
21.6
9.3
3.9
diagnosed with a sleep disorder.
Sleep disorder rates ranged from
5% to 14% across installations.
10%
Percent Diagnosed with a Sleep Disorder by Gender and Age,
AD Soldiers,2014
“Sleep is…important to public health,with sleep insufficiency linked to motor vehicle
crashes,industrial disasters,and medical and other occupational errors.Unintentionally
falling asleep,nodding off while driving,and having difficulty performing daily tasks be-
cause of sleepiness all may contribute to these hazardous outcomes.Persons experiencing
sleep insufficiency are also more likely to suffer from chronic diseases such as hypertension,
diabetes,depression,and obesity,as well as from cancer,increased mortality,and reduced
quality of life and productivity.”
—–Centers for Disease Control and Prevention

Health Factors
SLEEP DISORDERS
HEALTH FACTORS 60
In the FY2014 Performance
Triad Pilot, 86% of participat-
ing Soldiers indicated that
getting enough sleep was
very or critically important to
their physical performance
and 90% indicated that
getting enough sleep was
very or critically important
to their mental performance. Soldiers and leaders
easily recognized the association between quality
sleep and outcomes such as increased alertness,
improved decision making, improved morale,
decreased stress, increased safety, and increased
focus and/or brain function. They also noted that
lack of sleep negatively impacts their relationships
with other Soldiers and their Family members.
Despite recognizing the importance of quality
sleep and the troublesome impact of poor sleep,
more than four in five Soldiers indicated experienc-
ing barriers to optimal sleep. The most commonly
reported barriers to sleep included an inability to
sleep (31%), job responsibilities (31%), home and
family responsibilities (30%), and
a need to unwind before going
to sleep (25%). In focus groups,
Soldiers elaborated on what
leads to their sleeplessness. They
mentioned guard and staff duty
(24-hour duty), late night text
messages from Leaders, early
morning PT, work schedules and
work-related stress, video games,
time management, and person-
al choice to do other things as
sleep barriers. Soldiers further explained that lack
of sleep is “the Army way” and spoke to a perva-
sive culture of sleeplessness and sleep deprivation
within the military.
S P O T L I G H T
THE IMPORTANCE OF EFFECTIVE LEADERSHIP
IN PROMOTING SOLDIERS’ OPTIMAL SLEEP
Less than half of Soldiers participating in
the FY14 Performance Triad pilot agreed
or strongly agreed that their leaders mod-
eled positive sleep behaviors and only 40%
agreed that their leader coached them on
how to obtain adequate sleep.
–FY2014 Performance Triad Pilot Program Evaluation
INSTITUTIONALAGILIT
LEADERSHIP
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
Model
Army Culture:
Standards
Values
Facilities
Policies
Process
Training
Support
Unit
Institutional
Training
Self-
Development
Goals
Commitment
READINESS
PERSONALREADINESS
I
nsufficient sleep and sleep disorders are a threat to mission success. Challenging a military
culture that has historically discounted sleep is critical to ensuring Soldiers are getting the
sleep they need to perform at their best. While there are many resources that provide individ-
uals with tips related to achieve good sleep hygiene, individual education and behavior modifi-
cations are not enough. What can leaders do to support Soldiers in getting better sleep?
• Recognize signs of insufficient sleep and
sleep disorders in Soldiers. Educating your-
self about sleep and sleeplessness is a critical
first step in better understanding how to sup-
port Soldiers. More information can be located
on the “10 effective sleep habits for adults”
tip card or the Army Wellness Center Healthy
Sleep Habits presentation. Links to these re-
sources can be found in the references below.
• Communicate with Soldiers about sleep.
Many leaders perceive that sleep is a Soldier’s
individual responsibility and don’t engage in
conversations with their Soldiers about how
they are sleeping. Open the door to communi-
cation and prepare yourself with strategies and
resources to assist Soldiers who may be having
trouble. If a Soldier is showing signs of prob-
lems sleeping or a potential sleep disorder,
refer him or her to an Army Wellness Center or
patient centered medical home for assessment
and treatment.
• Set conditions in which Soldiers are able to
obtain adequate sleep. Staff duty or 24-hour
shift work is not conducive to alertness and
safety. While staff duty is a necessary part of
any unit, consider innovative ways to avoid
24-hour shifts, such as dividing the time into
shorter shifts? Consider providing a manda-
tory day off after staff duty and/or provid-
ing transportation to Soldiers for staff duty
responsibilities so they do not drive home
sleep-deprived.
• Facilitate a healthy sleep environment in
Soldiers’ barracks. Enforcing quiet times and
lights out can help Soldiers increase sleep
time. Dark, quiet and cool barracks with noise
and light discipline not only helps Soldiers
sleep but also trains them to manage sleep for
training and for sustained operations.
• Integrate sleep science into mission plan-
ning. Research on sleep banking and sleep
planning can be incorporated into Army mis-
sions. These tactics can help Soldiers prepare
for and recover from sustained operations or
longer training events such as those at the
National Training Center or Joint Readiness
Training Center.
• Serve as a role model. Soldiers are always
watching their leaders, and leaders should
exemplify readiness. Being knowledgeable is
an important first step, but demonstrating your
own good sleep habits will set the best exam-
ple for Soldiers to follow.
References:
Centers for Disease Control and Prevention. (2015). Sleep and Military. http://www.cdc.gov/features/sleep-military/index.html. Retrieved 8
October 2015.
U.S. Army Public Health Center. (2013, December). 10 effective sleep habits for adults tip card. Retrieved from https://usaphcapps.amedd.
army.mil/HIOShoppingCart/viewItem.aspx?id=531
U.S. Army Public Health Center. Healthy Sleep Habits presentation. Retrieved from https://usaphcapps.amedd.army.mil/HIOShoppingCart/
viewItem.aspx?id=715
U.S. Army Public Health Command (USAPHC). (2014, October). Performance Triad Evaluation of 6-month Pilot at Follow Up: Qualitative
Component, March 2014–May 2014. Public Health Assessment Report S.0022105-14. USAPHC: Aberdeen Proving Ground, MD.
U.S. Army Public Health Command (USAPHC). (October, 2013). The Activity, Nutrition, and Sleep Context within the 189th Combat
Sustainment Support Battalion at Fort Bragg, North Carolina and Associated Recommendations for Performance Triad Pilot Program
Implementation, 25-26 September 2013. Public Health Assessment Report No. No. S.0011581b-13. USAPHC: Aberdeen Proving Ground, MD.
U.S. Army Public Health Command (USAPHC). (2013, September). The Activity, Nutrition, and Sleep Context within the 4th Battalion, 6th
Infantry Regiment at Fort Bliss, Texas and Associated Recommendations for Performance Triad Pilot Program Implementation, 20-21 August
2013. Public Health Assessment Report No. S.0011581a-13. USAPHC: Aberdeen Proving Ground, MD.
U.S. Army Public Health Command (USAPHC). (2013, August). The Activity, Nutrition, and Sleep Context within the 3rd Squadron, 38th
Calvary Regiment at Joint Base Lewis-McChord, Washington and Associated Recommendations for Performance Triad Pilot Program
Implementation, September 2013. Public Health Assessment Report No. S.0011581-13. USAPHC: Aberdeen Proving Ground, MD.

Health Factors SUBSTANCE ABUSE
Substance Abuse
The misuse and abuse of alcohol, prescription
medication, and other drugs detract from indi-
vidual health and unit readiness, and negatively
impact the lives of Army Families and the com-
munity at large. The accidental or intentional
overdose of alcohol or drugs is a major cause of
morbidity and mortality; it is also the most com-
mon method of suicide attempt among Soldiers.
In addition, substance abuse disorders are asso-
ciated with domestic violence and sexual harass-
ment/assault incidents, which are threats to public
health and safety.
Approximately 2% of AD Soldiers had a diag-
nosed substance abuse disorder in 2014. The
proportion affected ranged from 1 to 3% across
installations. Men were disproportionately affect-
ed (2.0% compared to 1% for women), and preva-
lence was highest among Soldiers under 35 years
of age.
HEALTH FACTORS 62
Women Men
3 2
PercentPercent
1 0
Total
45+
35–44
25–34
25
0 1 2 3
2.0%1.3%
1.2%0.7%
1.7%1.0%
2.3%1.4%
2.0%1.4%
diagnosed with a substance
abuse disorder.
Rates ranged from 1% to 3%
2%
S P O T L I G H T
Army Substance Abuse Program (ASAP)
The Army Substance Abuse Program (ASAP) is responsible for providing guidance and leadership on all
non-clinical alcohol and other drug policy issues; developing, establishing, administering, and evaluating
non-clinical alcohol and other drug (AOD) abuse prevention, education, and training programs;
overseeing the Military, Drug Free Workplace and Department of Transportation biochemical (drug)
testing programs; and for the oversight of local Army Substance Abuse Programs (ASAP) worldwide.
The primary goal of the ASAP website is to provide soldiers, commanders, ASAP personnel, Unit
Prevention Leaders (UPL) and all other members of the Army community with an informative, user-friendly
online environment. Those utilizing the site have access to a multitude of information on our Biochemical
(drug) Testing Programs, Risk Reduction Program (RRP), Soldier Assistance Program (SAP), Employee
Assistance Program (EAP), alcohol and drug abuse prevention training materials, as well as general
information about our Agency. https://acsap.army.mil/
Percent Diagnosed with a Substance Abuse Disorder by Gender and
Age,AD Soldiers, 2014

Health Factors
SUBSTANCE ABUSE
HEALTH FACTORS 64
2012 Institute of Medicine report prepared
for the Department of Defense recom-
mended ways of addressing the problem
of substance use in the military. Recommendations
included increasing the use of evidence-based
prevention and treatment interventions and
expanding access to care.
Army leaders have recently expressed interest in
a single, integrated training to prevent substance
abuse, sexual assault, and suicide. A systematic
review of evidence supporting the integration of
substance abuse, suicide prevention, and sexual
assault trainings found that, to date, there is not
enough data to draw conclusions regarding the
effectiveness of integrated primary prevention
in these areas (that is, an evidence-based single
training to reduce substance abuse, sexual assault,
and suicide does not exist). However, the review
highlighted evidence-based best practices associ-
ated with substance abuse prevention. Character-
istics of effective training practices associated with
substance abuse reduction include:
• They are interactive, time insensitive, and universal
• They incorporate principles of positive psychol-
ogy and social learning
• They address changes to the environment
These principles should be incorporated whenever
possible into substance abuse prevention trainings
for Soldiers.
“Grappling with the public health crisis of substance use and misuse within the
ranks of the armed forces will require the DOD to consistently implement pre-
vention, screening, diagnosis, and treatment services and take leadership for
ensuring that these services expand and improve.”*
—Institute of Medicine
References:
Soole et al., 2006, Hersh et al., 2000, Deitz et al, 2005, Englander-Golden et al., 1996, Wambeam, 2013
STAND-TO! Edition: Monday August 19, 2013. Ready and Resilient Campaign: Polypharmacy. Retrieved at
http://www.army.mil/standto/archive_2013-08-20/
White Paper: Behavioral and Social Health Outcomes Program (BSHOP) Proposal for Polypharmacy and
Overdose Medical Education (POME) Training Program
A
An example of an Army training developed to
reduce substance misuse and abuse among warf-
ighters is the Polypharmacy and Overdose Medical
Education training.
Polypharmacy is defined as:
• Prescriptions for 4 or more of any type of medi-
cation, including one or more opioid within the
previous 30 days.
• Prescriptions for 4 or more medications from the 7
categories of psychotropics and Central Nervous
System Depressants within the previous 30 days.
• Three or more ER visits in the past year in which
an opioid was prescribed at each visit.
Recognizing the need to train medical providers
on polypharmacy and how to prevent it, the U.S.
Army developed POME. POME is a comprehen-
sive, interactive training module for healthcare
providers who prescribe medication. It describes
the doctor shopping phenomenon and how to
handle patients who seek narcotics from multiple
sources, characteristics of polypharmacy, and strat-
egies like medication reconciliation to enhance
patient safety. This module was developed in con-
sultation with the Uniformed Services University of
the Health Sciences and the Pharmacy Consultant
to TSG.
A specific video training for
Warrior Transition Unit (WTU)
staff (i.e., cadre, nurse case
managers, and social work-
ers) also illustrates how to
recognize signs and symp-
toms of medication misuse
and abuse, and a commu-
nication tool called “Look,
Listen, and Act” is applied to real life scenarios.
This module was developed in consultation with
the Psychiatry Consultant to TSG, the Addiction
Consultant to TSG, WTU nurse case managers,
licensed clinical social workers, clinical pharma-
cists, and pain management providers.
Per OTSG/MEDCOM Policy Memo 13-032 (Guid-
ance for Managing Polypharmacy and Prevent-
ing Medication Overdose in Soldiers Prescribed
Psychotropic Medications and Central Nervous
System Depressants, dated 21 May 2013), MED-
COM currently has a goal of 90% completion of the
initial and annual polypharmacy training by health-
care providers, pharmacists, and other healthcare
professionals.
S P O T L I G H T
POLYPHARMACY AND OVERDOSE MEDICAL
EDUCATION (POME)
“Members of the armed forces are not immune to the substance use problems
that affect the rest of society. Although illicit drug use is lower among U.S. mili-
tary personnel than among civilians, heavy alcohol and tobacco use, and espe-
cially prescription drug abuse, are much more prevalent and are on the rise.”*
—National Institute of Drug Abuse
*Source: https://www.drugabuse.gov/publications/drugfacts/substance-abuse-in-military
LEADERSHIP
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
Model
Army Culture:
Standards
Values
Facilities
Policies
Process
Training
Support
Unit
Institutional
Training
Self -
Development
Goals
Commitment
READINESS
PERSONALREADINESS

Health Factors
Chlamydia
Sexually transmitted infections such as chla-
mydia can impact medical readiness and Soldier
well-being. Most people infected with chlamydia
are unaware because they have no symptoms. If
left untreated, chlamydia may cause severe health
complications, particularly among women, who
may experience pelvic inflammatory disease, ec-
topic pregnancy, and infertility. Therefore, it is rec-
ommended that pregnant women, sexually active
women under 25 years old, and older women with
risk factors get screened annually for chlamydia.
Approximately 16.7 chlamydia infections per 1,000
Soldiers were reported in 2014. Rates ranged from
9.5 to 25.9 per 1,000 across the ranked installa-
tions. Rates were nearly four-fold higher among
women, particularly women under 25 years of age,
where 76.8 infections per 1,000 were reported.
This may be partially due to increased screening
among this demographic. Higher reported rates
as well as higher screening compliance have been
documented among Soldiers as compared to sim-
ilar demographic cohorts in the U.S. population.
CHLAMYDIA
HEALTH FACTORS 66
Overall, 17 new chlamydia
infections were reported per
1,000 Soldiers.
Reported chlamydia rates ranged
from 7 to 28 per 1,000 across
installations.
17
Women Men
Rate per 1,000 Rate per 1,000
Total
45+
35–44
25–34
25
001020304050607080 10 20 30 40 50 60 70 80
12.8
1.5
3.2
10.4
20.5
40.8
2.5
6.3
22.0
76.8
Rate of Chlamydia Reported by Gender and Age,AD Soldiers, 2014
Annual chlamydia screening for sexually active females
25 years was ranked by the National Commission on
Prevention Priorities as one of the 10 most beneficial and
cost-effective prevention services.
—Macioseket al, Am J PrevMed 2006

Health Factors
CHLAMYDIA
HEALTH FACTORS 68
Chlamydia is the most prev-
alent reportable disease for
the U.S. and the U.S. military.
Reported cases are routinely
tracked both nationally and
within the Army. This type of
surveillance is beneficial for
identifying and targeting high-
risk groups for disease preven-
tion which can also reduce the
transmission of other sexually transmitted infec-
tions (STIs). However, rates are considered con-
servative given that the majority of infections are
asymptomatic and go undetected. Under-reporting
is also problematic, further limiting estimates.
Due to surveillance enhancements with the mil-
itary’s Disease Reporting System internet (DRSi),
under-reporting can now be more readily explored.
Using a relatively new DRSi case-finding module
which detects probable cases from laboratory
data, a significant reporting issue was discovered,
affecting roughly half of the installations evaluated.
These installations had less than 60% of identi-
fied probable cases reported through DRSi which
diminished the confidence of the reported rates.
These case-finding estimates are preliminary and
warrant further investigation to determine under-
lying causes, and suggest the need for additional
education regarding reporting.
Improved education will allow clinicians and pub-
lic health professionals to use DRSi and the new
case-finding resource effectively. Additional infor-
mation can be obtained at:
http://phc.amedd.army.mil/topics/healthsurv/de/
Pages/DRSiResources.aspx
The Army Medicine 2020 Campaign Plan
outlines objectives to promote responsi-
ble sexual behavior. As a result, the Pro-
mote Responsible Personal and Social
Behavior (PRPSB) program was estab-
lished. The PRPSB takes a multi-fac-
eted approach that incorporates
a variety of measures to improve
STI surveillance, prevention, and
treatment. As part of this initiative,
monthly rates of two reportable STIs (chlamydia and
gonorrhea), STI reporting timeliness, and STI follow-up
(e.g., contact tracing) are monitored at Army instal-
lations. A standardized educational briefing has been
developed for implementation across Army installations,
and other educational and prevention resources and poli-
cies continue to be developed. The PRPSB program guide
is anticipated to be released in October 2015.
S P O T L I G H T
S P O T L I G H T
AMEDD’s Promote Responsible Personal and Social Behavior
(PRPSB) Program
Disease Reporting System internet (DRSi)
surveillance
prevention
treatment
TITUTIONALAGI
LEADERSHIP
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
Model
Army Culture:
Standards
Values
Facilities
Policies
Process
Training
Support
Unit
Institutional
Training
Self-
Development
Goals
Commitment
READINESS
PERSONALREADINESS
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
Model
Army Culture:
Standards
Values
Facilities
Policies
Process
Training
Support
Unit
Institutional
Training
Self-
Development
Goals
Commitment
READINESS
STITUTIONALAGIL
Nearly 40% of AD Army Soldiers are
under 25 years of age; by age alone,
many AD Soldiers are at higher risk
for STIs.
All STIs are preventable, many are curable and
all can be treated. Effective ways to reduce risk
include:
• Using a condom correctly every time when
engaging in oral, vaginal or anal sex
• Reducing the number of sexual partners and the
number of high-risk partners, situations and sex
acts
• Being in a mutually monogamous relationship
with an uninfected partner
• Talking to a medical provider about getting test-
ed (every three to six months)
• Getting the HPV and Hepatitis B vaccines
Roughly half of all new STIs in the U.S. occur among 15–24 year olds.
STI Statistics
Prevention Tips
The CDC estimates there are 20 million new sexually transmitted infections (STIs) in
the U.S. each year, and more than 110 million total STIs (new and old infections).
STIs COST THE AMERICAN HEALTHCARE SYSTEM
NEARLY $16 BILLION IN DIRECT MEDICAL COSTS ALONE.$ $
Gonorrhea
333,004
Cases Reported
Chlamydia
1,401,906
Cases Reported
22%
1%
1%
0–14 15–19 20–24 25–29 30–39 40+
34% 19% 16% 9%
28% 39% 17% 11% 4%
Percentages may not add to 100 because ages were unknown for a small number of cases
Common STIs include human papillomavirus (HPV),
chlamydia, trichomoniasis, gonorrhea, herpes
simplex virus (HSV), syphilis, hepatitis B and human
immunodeficiency virus (HIV).
STIs often have no noticeable symptoms. Chla-
mydia, for example, fails to show symptoms in
about 80% of infected women and 50% of infected
men. And having an STI can make it easier to
become infected with another. Periodic STI testing
is often the best way to identify infections.

Healthcare Delivery
PREVENTABLE HOSPITAL ADMISSIONS
Preventable
Hospital Admissions
Preventable admissions include those for acute
illness, such as dehydration or urinary infections,
and for exacerbated chronic conditions, such
as diabetes, that could have been avoided with
appropriate outpatient care. These admissions
reflect an avoidable and costly healthcare burden
and suggest sub-optimal quality of outpatient care
or overuse of hospitals as a primary source of care.
The Army Medical Command (MEDCOM) tracks
these rates monthly for Army Active Duty enrollees.
Rates are reported via the Command Manage-
ment System (CMS) along with the MEDCOM tar-
get, which is currently set at 3.5%. The U.S.-based
Army installations evaluated fell well below this
target at 2%. The proportion of hospitalizations
affected ranged from 1% to 5% across installations.
However, there is room for improvement given
that three installations exceed this target, with
percentages approaching 5%.
HEALTHCARE DELIVERY 70
Hospital costs for potentially preventable
hospitalizations represented about one of
every 10 dollars of total hospital expendi-
tures in 2006.
Source: Agency for Healthcare Research and Quality
Overall, 2% of Soldier hospital
admissions were classified as
preventable.
Rates ranged from 1% to 5%
2%
“PROGRAMSTO PREVENT CHRONIC DISEASES
GENERATE SAVINGS BY LOWERING RATES OF
HOSPITALIZATIONS.FOR EXAMPLE,PATIENT-
CENTERED MEDICAL HOMES GENERATE MOST OF
THEIR SAVINGS BY REDUCING HOSPITALIZATIONS.
— CENTERS FOR DISEASE CONTROLAND PREVENTION
”

Healthcare Delivery PREVENTABLE HOSPITAL ADMISSIONS
Potentially preventable hospitalizations are
admissions to a hospital for certain acute illnesses
or worsening chronic conditions that might have
been avoided with the delivery of high-quality
outpatient treatment and disease management.
They can serve as potential markers of health sys-
tem efficiency. Lack of access to healthcare and
poor-quality care can lead to increases in these
types of hospitalizations.
Hospital care represents the largest component
of overall healthcare expenditures. Thus, reduc-
ing the frequency of potentially preventable hos-
pitalizations would be an effective strategy for
lowering costs while improving quality of care and
patient outcomes.
Source: Agency for Healthcare Research and Quality
S P O T L I G H T
COMMAND MANAGEMENT SYSTEM (CMS)
The Army MEDCOM tracks prevent-
able admission rates on a monthly
basis for most of its military treat-
ment facilities (MTFs) on the Com-
mand Management System (CMS).
The CMS provides a timely means to
assess outcomes, identify needs and
improve efficiency. An MTF’s perfor-
mance for this and other healthcare
delivery metrics may be monitored
at: https://cms.mods.army.mil/cms/
NSTITUTIONALAGILI
LEADERSHIP
PERSONALREADINESS
REALISTIC TRAINING
Lead,
Coach,Teach,
Mentor,
Model
Army Culture:
Standards
Values
Facilities
Policies
Process
Training
Support
Unit
Institutional
Training
Self-
Development
Goals
Commitment
READINESS
PERSONALREADINESS
INSTALLATION PROFILE SUMMARIES 72
INSTALLATION HEALTH INDEX
*
* Installation profile summaries are provided in alphabetic order

2015 Army Health of the Force report

2015 Army Health of the Force report

Recommended

Recommended

More Related Content

Similar to 2015 Army Health of the Force report

Similar to 2015 Army Health of the Force report (20)

More from JA Larson

More from JA Larson (20)

Recently uploaded

Recently uploaded (20)

2015 Army Health of the Force report